<form method="POST">
<fieldset>
<legend>Please Fill Out The Following Form:</legend>
<br> Name of Patient: <input type="text" name="patient_name" />
DOB: <input type="text" name="patient_birthdate"/><br />
Hospital <input type="text" name="hospital" />
Department of Treatment  <input type="text" name="dept"/> <br/>
Name of Referring Social Worker: <input type="text" size="15" name = "social_worker" /><br />
 <br/>


<fieldset>
<legend>Primary Guest Information:</legend>
First Name: <input type="text" size="30" name="first_name" /><br />
Last Name: <input type="text" size="30" name="last_name"/><br />
Relationship to Above Patient: <input type="text" size = "30" name= "patient_relation"/><br />
Home Address: <input type="text" size="40" name = "address"/><br />
City: <input type = "text" size = "15" name = "city"/> 
State: <select name = "state">
  <?php

			$states = array("AL","AK","AZ","AR","CA","CO","CT","DE","DC","FL","GA","HI","ID","IL","IN","IA",
					        "KS","KY","LA","ME","MD","MA","MI","MN","MS","MO","MT","NE","NV","NH","NJ","NM",
					        "NY","NC","ND","OH","OK","OR","PA","RI","SC","SD","TN","TX","UT","VT","VA","WA",
					        "WV","WI","WY");
			foreach ($states as $st) {
				echo "<option>" . $st ."</option>";
			}
		?>
</select>
Zip: <input type = "text" size = "5" maxLength = "5" name="zip" /> <br />
E-mail: <input type="text" size="30" name="email" /><br />
Phone #: <input type = "text" size = "10" maxLength = "10" name="phone1" /> 
Alternate Phone # <input type = "text" size = "10" maxLength = "10" name="phone2" /> <br />
</fieldset>

<br />
<input type="button" name="test" value=" + " 
onclick="alert('Working on it');"> Click to Add Another Primary Guest

<br />
<br />

<b> Additional Guests </b> <i>(Immediate family or support person(s))</i>:
<table border="1">
<tr>
<th>Name</th>
<th>Relationship to Patient</th>

<?php
  for ($counter = 1; $counter <= 4; $counter += 1){
     echo
		'<tr>
		<td><input type="text" size="15" name = "additional_guest'.$counter.'"/></td>
		<td><input type="text" size="22" name = "additional_guest'.$counter.'_relation"/></td>
		</tr>';
  }
?>
</table>
<br />
<b>Select Payment Arrangement:</b><br />
<input type="radio" name="payment" value="$10" /> $10 per night<br />
<input type="radio" name="payment" value="other" /> Other:  <input type="text" name="payment" size="20" /> <br />
<br />

<b>Select Priority</b> <br />
<input type="radio" name="priority" value="1" /> 
	1. SCU, NICU, High-Risk Prenatal<br />
<input type="radio" name="priority" value="2" /> 
	2. In-Patient Pediatrics, MCCP Out-Patient Treatment Stays<br />
<input type="radio" name="priority" value="3" /> 
	3. Other: Specialist Appointments, Spring Harbor Hospital, <br /> 
	Mercy Westbrook, Eating Disorder Program <br />
<br />

<b>Check Approved Use(s): </b> <br />
<input type="checkbox" name="use[]" value="overnight" /> Overnight<br />
<input type="checkbox" name="use[]" value="day" /> Day <br />
<br />

<b>Select one of the following: </b> <br />
 <input type="radio" name="visitOrWC" value=visitDate /> Will Visit 
    <i>(Date of Initial Visit:  <input type="text" name="visitDate" size="8" /> ) </i><br />
<input type="radio" name="visitOrWC" value="Will Call" /> Will Call

</fieldset>
<input type="submit" value = "Submit" name = "submit"/>
</form>